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NATIONAL UNIVERSITY OF HCM INSTITUTE OF SOCIAL STUDIES UNIVERSITY OF ECONOMICS THE HAGUE VIETNAM THE NETHERLANDS VIETNAM-THE NETHERLANDS PROJECT FOR M.A ON DEVELOPMENT ECONOMICS DETERMINANTS OF COMMUNE HEALTH CENTER (CHC) USAGE IN LONG AN PROVINCE A thesis submitted in partial fulfillment of the requirements for the degree of MASTER OF ARTS IN DEVELOPMENT ECONOMICS BY HUYNH DANG BICH VY Academic Supervisor: DR NGUYEN VAN PHUC BQ GIAO DVC VA 8AO -;-; ; TRVdNG E>H KINH TE TP.I·ic;·.~ THUVIEN j; ( ~c }f- HO CHI MINH CITY, AUGUST 2007 ACKNOWLEDGEMENTS Firstly, I would like to express my deep gratitude to all professors and teaching staff in Vietnam-Netherlands programme on Development Economics for their lectures, instructions and the best teaching conditions during my study period from 2004 to present The author would like to give a special thanks to Dr Nguyen Van Phuc, the author's supervisor, for his scientific instructions and his valuable comments on this study In addition, the author owes special gratitude to Mr Truong Dang Thuy and Mr Luong Vinh Quoc Duy for their enthusiastic help and criticism This research would have been completed difficultly were it not for the kind and warm welcome of individuals from over 100 households in Can Duoc and Can Giuoc district during the survey Thanks are due to many friends that I could not fully list here for their strong supports of the survey and their invaluable encouragements and nice wishes And last but not least, all my love is devoted to my parents and brother who always help and encourage me during my learning and doing this study Again, the author is really grateful to all people for their help Any errors in this research are my responsibility alone CERTIFICATION I certify that the substance of this thesis has not already been submitted for any degree and is not being current submitted for any other degree I certify that to the best of my knowledge any help received in preparing this thesis, and all sources used, have been acknowledged in this thesis HUYNH DANG BICH VY ABSTRACT Many studies of the utilization of health care system have been done in different countries over the world In most developing countries like Vietnam, people mainly live in rural area; hence rural health care sector plays an important role One of health care providers is commune health center that provides basic health care Therefore, this study's purpose is to investigate determinants of commune health center usage; specifically it aims at examining the effects of individual income Binary logit model was used to find out the answers for the questions of what determinants of using health care services from CHC are and whether with higher income people tend to use more CHC services or not The author has applied the method of multi-staged sampling to collect data in Can Duoc and Can Giuoc districts, Long An province The object of this research is individuals aged 15 and older that are the adult population and have enough civil capacity to make their own decisions The results show that income is a relatively important determinant of CHC -cnoice -in.-can Duoc and-Catlviuo-c-districts:-Furthermore;-other-factors-such-as- socio-demography, severity of illness and characteristics of the CHC provider are significantly important These results are useful to give several recommendations to improve the quality of CHC services in order to satisfy particular income group TABLE OF CONTENTS CHAPTER 1: INTRODUCTION 1.1.PROBLEM STATEMENT 1.2 RESEARCH OBJECTIVES 1.3 RESEARCH QUESTIONS 1.4 METHODOLOGY 1.5 HYPOTHESIS 1.6 RESEARCH SCOPE 1.7 THESIS STRUCTURE CHAPTER 2: LITERATURE REVIEW 2.1.DEFINITIONS 2.2.THEORY OF CONSUMER BEHAVIOR 2.3 THEORIES OF FACTORS AFFECTING HEALTH CARE DEMAND 2.4.MODEL 2.5.SUGGESTED RESEARCH VARIABLES CHAPTER 3: AN OVERVIEW OF HEALTH CARE PROVIDER IN VIETNAM 3.1.BACKGROUND ON VIETNAMESE HEALTH CARE SYSTEM 3.1.1.Achievements 3.12 Shortcomings 3.2.COMMUNE HEALTH CENTER CHAPTER 4: RESEARCH METHODOLOGY, ESTIMATION AND RESULS •••••.••••• 27 4.l.DATA COLLECTION METHODS 4.1.1.Sampling technique 4.1.2.Sample size 4.2.DATA 4.2.1.The main contents ofthe questionnaire 4.2.2 Dependent variable 4.2.3 IndeJJendent variables 4.2 3.1 Socio-demographic characteristics 4.2.3.2 Individual and household income 4.2.3.3 The characteristics ofthe perceived illness 4.2.3.4 Attributes ofhealth care provider and the non-monetary cost 4.3.STRENGTH AND WEAKNESS OF COLLECTED DATA 4.4.REGRESSION RESULTS CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS 5.l.CONCLUSIONS 5.2.RECOMMENDATIONS REFERENCES: APPENDICES: APPENDIX 1: APPENDIX 2: APPENDIX 3: LIST OF TABLES TABLE 2.1: The expected signs ofdeterminants ofhealth care usage 17 TABLE 3.1: Infrastructure in three levels ofpublic health care system in 2006 in Vietnam 23 TABLE 3.2: The proportion ofout-patient health service contacts ofeach level of income people at each type ofprovide 25 TABLE 4.0: Appropriate sample size 29 TABLE 4.1: The number and the percentage ofobservations for each type ofproviders 30 TABLE 4.2: Basic socio-demographic characteristics ofthe respondents 31 TABLE 4.3: Average income of respondent and average income per capita per month 32 TABLE 4.4: Mean individual income offive groups 33 TABLE 4.5 Choice ofprovider by income quintile 33 TABLE 4.6: Results ofthe survey CHC andnon-CHC respondents in terms oflDAY 34 TABLE 4.7: Results ofthe survey CHC and non-CHC respondents in terms ofRDAY 35 TABLE 4.8: Availability ofdrugs in the CHC 36 TABLE 4.9: Total expenditure for consultation and drugs 37 TABLE 4.10: The number ofobservations that people have used specific health care provider 38 TABLE 4.11: Data definitions 39 TABLE 4.12: Logit regression results 43 TABLE 4.13: The changes in the probability ofusing CHC provider if having change in -ageCJrlevel-of-education;-given-otherfactors ;-;;-=;-.-;-;-;~-.-.-;-;-;-;;-;,-;o.;;-;-;-;;~-.=•• ••- ,•• ,-.-.-.-.-.•••••••• 44-TABLE 4.14: The changes in the probability ofCHC usage ofmale and female if age increases by one year, given other factors 45 TABLE 4.15: The changes in the probability ofCHC usage of male and female if the ratio ofdistance increase by one unit, given other factors 45 TABLE 4.16: The changes in the probability ofCHC usage ofmale and female if the user fee ofCHC is cheaper, given other factors 46 TABLE 4.17: The changes in the probability ofCHC usage if changing severity of illness, given other factors 47 TABLE 4.18: The changes in the probability ofCHC usage as having change in income, given other factors 48 TABLE 4.19: Descriptive statistics of variables ,.56 TABLE 4.20: Correlations among independent variables 58 LIST OF FIGURES FIGURE 2.1: The behavioral model FIGURE 2.2: Choice ofa health care provider .8 FIGURE 3.1: Total expenditure on health (THE) as% ofGDP 20 FIGURE 3.2: Total expenditure on health in million VND for 1996-2005 20 FIGURE 3.3: Inequality in the use ofhealth services 22 FIGURE 3.4: Proportion ofout-patient health care service visits by type ofprovider 24 FIGURE 3.5: Main reasons for choosing outpatient facility used 25 ACRONYMS CHC Commune Health Center GSO General Statistics Office LHS Left Hand Side MOH Ministry of Health MTEF Medium-Term Expenditure Framework RHS Right Hand Side SD Standard Deviation UNDP United Nations Development Programme UNICEF United Nations Children's Fund VDR Vietnam Development Report VLSS Vietnam Living Standards Survey VNHS Vietnam National Health Survey WB World Bank WHO World Health Organization CHAPTER I INTRODUCTION The introduction chapter consists of six parts The problem statement is presented in section 1.1 The following parts such as research objectives, research questions, methodology, and hypothesis are in section 1.2, 1.3, 1.4, and 1.5, respectively Research scope as well as several reasons for choosing Can Duoc and Can Giuoc districts as research places is revealed in section 1.6 The last section is thesis structure 1.1 Problem statement Health sector is one of main concerns of many countries in the world as well as in VietNam During the period since Doi Moi (Renovation) to the present, the government has invested resources and implemented many reforms in this sector The rural heath care system is strengthened as the government's priority because around 72.9% of 84,108 million Vietnamese people live in rural area (UNDP, 2006) It is organized at four levels: national, province, district, and commune (Tran Tuan, 2004) Together with private providers and self-medication, almost all communes have a commune health centre (CHC) According to Nanak Kakwani and Hyun H:-Son -(2U01i)~-CHC seems to play an-impoftantrole_in providing basic health services to the poor in Viet Nam In particular, CHC is responsible for primary curative care service in a community, especially in rural area However, the role of the commune health center has declined One of the reasons of this is that a large part of primary curative care service is shared with other providers Another reason is that people tend to seek higher quality health care services because of an improvement of living standard The CHC system only retains its dominant role in preventive care (Tran Tuan, 2004) This study investigates determinants of CHC usage and finds out whether CHC is normal or inferior goods, especially in two districts of Long An province, namely, Can Duoc and Can Giuoc This kind of information would help decision makers develop appropriate plan for CHCs Since, suppliers could provide appropriate health care services and contribute to conduct an accessible and affordable health service to consumers Therefore, this research concentrates on investigating determinants of commune health center usage in Can Duoc and Can Giuoc districts, Long An provmce 1.2 Research objectives General objective is to examine the factors affecting commune health center usage in Can Duoc and Can Giuoc districts, Long An province Specific objectives are to measure the effect of individual income on CHC usage and to propose appreciate plan for CHCs to satisfy the demand for health care services of people living in the two research places 1.3 Research questions A general question is: what are determinants of using health care services fromCHC? And the other is: Are individuals with higher income more likely to use health care service from CHC? 1.4 Methodology Descriptive methods are used to review the background conditions of Vietnamese health care system, especially health care information from survey in Long An province Moreover, an econometric model is formulated to examine the relative effects of various determinants of CHC usage In particular, the author applied binary logit model to find out answers for the above research questions 1.5 Hypothesis The study hypothesis is that there is a negative relationship between individual income and CHC usage in rural area The higher income is, the higher demand for health care facilities with high quality such as public or private hospitals, private clinics is As a result, demand for CHC usage will reduce HOUSEHOLD MEMBER'S INCOME INFORMATION DATE: / I DISTRICT: COMMUNE: HOUSEHOLD CODE: ! I Note: if interviewer can not ask detail, you should ask the ~verage income of each member A.WORKER mcome Member code (from bonus, subsidy ) per year? months you work per year? ! • ! 65 13 Total HOUSEHOLD MEMBER'S INCOME INFORMATION DATE: / / DISTRICT .COMMUNE: IIOlJSEIIOI.D CODE: B AGRIClJLTlJRE: 14.Is this income household or Member Which code you cu personal Personal D llousehold Farm p D Indust Others Personal D llousehold Farm p D Indust Others Personal D llousehold Farm p Indust D Others 66 I HOUSEHOLD MEMBER'S INCOME INFORMATION DATE: / ! •.• DISTRICT I COMMUNE: I HOUSEHOLD CODE: I C_BREEDING + AQUICULTURE: 20 Is this mcome household or personal? Member 21 Which animal yo code Cattle: Poultry:2 Fish:3 Others: Personal D Household D Personal D Household D Personal D Household D Personal Household D D HOUSEHOLD MEMBER'S INCOME INFORMATION DATE: / ! DISTRICT COMMUNE: HOUSEHOLD CODE: D- SERVICES: 26.Is this income household personal? or Member 27 Which service code you do? Tilling: Insect preventing: Irrgation: Product preliminary: Others: Personal Household Personal Household 0 INFORMATION OF PERSON'S ILLNESS/ INJURY Household code: Ill person code: 37 When did you have illness/ injured in the most recent? The kind of illness a) Bronchitis b) Diarrhea c) Gastritis d) Conjunctivitis e) Piss poisoning Tonsillitis f) g) Sinusitis h) Sore throat i) High blood pressure j) Rhinitis k) Injured The first treatment: 39 Being ill/ injured, did you get a cure immediately? Yes o (going on question 41) 40 No o (going on question 40) If you did not have a cure immediately, how many days after did you have treated for your illness/ injury after? days 41 a) CHC o Which facility did you choose for the treatment? b) Private clinic o c) Self-medication o 69 d).Other o 42 Did you have re-treatment? Yes D (If Yes, it will be the different observation) NoD 43 If not having re-treatment: If having re-treatment: a/ How many days did you use drugs for 43 b/ How many days did you use treatment ? days drugs b/ How many days did it take to get over days before re-treatment? the illness? days 44 Did the patient have to take days off from your work/study/daily work? Yes D (going to question 45) 45 No o (going to question 46) How many days did the patient have to take days off from your work/ study/ daily work? days In question 41, if the answer is CHC, going on question 7, 48 In question 41, if the answer is not CHC, going on question 46,47 46 How far is it from your house to the cho 47 How far is it from your house to the C 48-; How-far-is-it-from-your-house-to-the_neare_st facility1~ 49 How you go to the chosen facility? a) By walking D 50 How 'li ? f act ty 51 How much was the cost spent for the consultation? 52.How much was the VND => 70 In question 41, if the answer is CHC, going on question 54, 55 In question 41, if the answer is not CHC, going on question 53, 54 53 How long did it take to wait for consultation and buy drugs at this chosen li ? f ac1 ty 54 In your opinions, how long does it take to wait for consultation and buy drugs at CHC provider? minutes 55 In your opinions, how long does it take to wait for consultation and buy drugs at N' d1uerent prov1 er mmutes 56 Have you ever chosen CHC provider for your treatment? Yes o 57 Have you ever chosen private clinic for your treatment? Yes o 58 Have you ever chosen self-medication for your treatment? Yes o Note: in question 59, 60, interviewers will ask the respondents' subjective opinions 59 Compare the cost of consultation of CHC to other facilities'? a).Cheaper o b).More expensive o c).Similar o d).You not know o 60 Compare the cost of drugs of CHC to other facilities'? a).Cheaper o 61 b).More expensive o Did you have health insurance? 62~ In-your c).Similar o Yes o d).You not know o NoD opinions,-is-there-drugs available in_CHC? _ a).Yes o b) No o c)You not know o 63 Why don't you use CHC provider? (can choose many reasons) a) CHC is not clear b) Too far from your house c) The staff are not good d) The quality of services is not good, even too bad e) You not trust them f) It takes long time to wait for consultation 71 "d ? g) Others : (7) 72 Household code: Ill person code: The second treatment: (the same illness of the first treatment) 41 Which facility did you choose for the treatment? a) CHC o b) Private clinic o c) Self-medication o d).Other o 42.Did you have re-treatment? Yes o No o 43.If not having re-treatment: a/ How many days did you use drugs for treatment ? b/ How many days did it take to get over the illness? 44 Did the patient have to take days off from your work/study/daily work? Yes o (going to question 45) No o (going to question 46) ·~45~Huw-many-days-did the-patient-ha-ve-to-take_da}'Loff fr.mn_y_ol.